Caesarean Section: An interactive session

1. ABOUBAKR ELNASHAR
Caesarean Section
An interactive session

2. 1. WHAT IS DEFINITION OF EMERGENCY CS?
1. Within 30 minutes
2. Within 75 minutes
3. Needing early delivery but no maternal or fetal
compromise
4. At a time to suit the patient and the maternity
team
ABOUBAKR ELNASHAR

3. Immediate threat to life of woman or
fetus: Within 30 minutes
1-Emergency
Maternal or fetal compromise which is
not immediately life threatening
Within 75 minutes
2-Urgent
Needing early delivery but no maternal
or fetal compromise
Proper decisions about rapid delivery.
Rrapid delivery may be harmful in
certain circumstances
3-Scheduled
At a time to suit the patient and the
maternity team
4-Elective
NICE Guideline November 2011
Decision-to-delivery interval for CS
ABOUBAKR ELNASHAR

4. 2. WHAT IS TIMING OF PLANNED CS?
1. 37 w
2. 38 w
3. 39 w
4. 40 w
ABOUBAKR ELNASHAR

5.  The risk of respiratory morbidity is increased in
babies born by CS before labour, but this risk
decreases significantly after 39 w:
planned CS should not routinely be carried out
before 39 Ws.
• Medically/obstetrically indicated CS are performed
when clinically indicated, without assessment of
fetal lung maturity.
(NICE , 2004 & 2011 [Grade B ])
ABOUBAKR ELNASHAR

6. 3. HOW TO PREVENT RDS?
1. Repeated Corticosteroids courses
2. Single corticosteroid course
3. Dexamethasone 6 mg/12 hs for 4 doses
4. Corticosteroid only before 35 w
ABOUBAKR ELNASHAR

7. Prophylactic Corticosteroids:
 Dexamethasone
 6mg/12 h for 4 doses
 significantly decrease admission to the
neonatal ICU for respiratory morbidity
 {It Improves alveolar fluid drainage}
 It is for CS Category 4 (Elective)
(Sotiriadis et al Cochrane SR, 2009).ABOUBAKR ELNASHAR

8. 4. HEMATOLOGICAL INVESTIGATION BEFORE CS:
What is correct?
1. Pregnant women should be offered haemoglobin
2. CS for APH should be carried out at a maternity
unit with on-site blood transfusion services.
3. Eclampsia is not risk factor for blood transfusion
4. Clotting screen is indicated before CS in
uncomplicated pregnancies
ABOUBAKR ELNASHAR

9.  Pregnant women should be offered haemoglobin
assessment before CS to identify those who have
anaemia.
 Although blood loss of >1000 ml is infrequent after CS
(4-8% of CS) it is a potentially serious complication
 Pregnant women having CS for APH (abruption, P.
praevia) are at increased risk of blood loss of >1000
ml:
CS carried out at a maternity unit with on-site
blood transfusion services.
(NICE Guideline 2004 & 2011)
ABOUBAKR ELNASHAR

10. Risk factors for requiring Blood transfusion
include :
 Placental abnormalities: previa, accreta, or
abruption
 Eclampsia or HELLP syndrome
 Preoperative hematocrit <25 %(HB 8.5g/d)
 Use of general anesthesia
 History of ≥5 CS
(Berghella , UpTpoDate,2016)
ABOUBAKR ELNASHAR

11. Pregnant women who are healthy with
uncomplicated pregnancies should not routinely be
offered the following tests before CS:
 Cross-matching of blood
 Clotting screen
(NICE , 2004, 2011)
ABOUBAKR ELNASHAR

12. 5. WHAT ARE INDICATIONS A FOLEY S CATHETER?
1. Regional anaesthesia
2. General anaethesia
3. Repeat CS
ABOUBAKR ELNASHAR

13. Indwelling Urinary Catheter
 Women having CS with regional anaesthesia
require an indwelling urinary catheter to prevent
over-distension of the bladder
{anaesthetic block interferes with normal bladder
function}.
(NICE , 2004 & 2011)
 There is no convincing evidence that routine
placement of an indwelling catheter is advantageous
(Berghella , UpTpoDate,2016)
ABOUBAKR ELNASHAR

14. 6. ANTIBIOTIC PROPHYLAXIS FOR CS: ALL ARE
TRUE EXCEPT?
1. Antibiotics are given 0 to 60 minutes before
making the incision.
2. They reduce the risk of postoperative infections.
3. Single IV dose of a narrow-spectrum
antibiotic, such as cefazolin
4. Co-amoxiclav is recommended in pretem
ABOUBAKR ELNASHAR

15.  Antibiotic Prophylaxis for CS
 Preoperative antibiotic prophylaxis rather than
after cord (Grade A )
 Antibiotics are given 0 to 60 minutes before
making the incision.
 They reduce the risk of postoperative infections.
(NICE , 2011; Berghella , UpTpoDate,2016)
ABOUBAKR ELNASHAR

16.  Choose antibiotics
 Effective against endometritis, UT and wound
infections, which occur in 8%
 Single IV dose of a narrow-spectrum antibiotic,
such as cefazolin
 2 gm for patients <120 kg
 3 gm for patients ≥120 kg
 Multiple doses are more costly, without clearly
improving outcome.
 Do not use co-amoxiclav in preterm when giving
antibiotics before skin incision.
 Clindamycin and Gentamicin for women with
serious penicillin allergy
(NICE , 2011; Berghella , UpTpoDate,2016)
ABOUBAKR ELNASHAR

17. 7. FOR THROMBOPROPHYLAXIS ALL ARE
CORRECT EXCEPT
1. For all women undergoing CS, mechanical
thromboprophylaxis is advisable.
2. For women undergoing CS at high risk of DVT,
mechanical thromboprophylaxis plus
pharmacological thromboprophylaxis are
recommended.
3. Pharmacologic prophylaxis is begun 24 h
postoperatively
4. Mechanical and pharmacological prophylaxis are
continued until the woman is fully ambulating
5. Prophylactic dose of Enoxaparin (Clexane) is 80
mg/d for wt 50-90 kgABOUBAKR ELNASHAR

18. Thromboprophylaxis
 For all women undergoing CS, mechanical
thromboprophylaxis is advisable (Grade 2C).
 For women undergoing CS at high risk of DVT,
mechanical thromboprophylaxis plus
pharmacological thromboprophylaxis are
recommended (Grade 2C).
 Pharmacologic prophylaxis is begun 6 to 12 h
postoperatively, after concerns for hemorrhage
have decreased.
 Mechanical and pharmacological prophylaxis are
continued until the woman is fully ambulating
(NICE , 2004 & 2011Berghella , UpTpoDate, 2016)
ABOUBAKR ELNASHAR

19.  Thromboprophylaxis should be offered because the
increased risk of venous thromboembolism at CS
 Graduated stockings
 Hydration
 Early mobilization
 Unfractionated or LMW heparin
(NICE; 2011)
ABOUBAKR ELNASHAR

20. 8. INDICATIONS OF ANTEPARTUM
CONSULTATION WITH AN
ANESTHESIOLOGIST:
1. Women with coagulopathy
2. Severe obesity
3. Restriction or abnormality of the spine
4. Cardiovascular or respiratory disease.
5. All of the above
Grant ,UpToDate, 2016ABOUBAKR ELNASHAR

21. 9. WHICH OF THE FOLLOWING IS WRONG?
1. General anaesthesia is safer and results in less
maternal and neonatal morbidity than regional
anaesthesia.
2. For General anaesthesia reduction of gastric acidity
is recommended
3. Preoxygenation is recommended
4. The operating table for CS should have a lateral tilt of
15 degrees
ABOUBAKR ELNASHAR

22.  Regional anaesthesia is safer: less maternal and
neonatal morbidity than general anaesthesia.
 This includes women who have a diagnosis of
placenta praevia.
 For General Anaesthesia for CS
 Reduction of gastric acidity: to prevent Mendelson
Syndrome
 Nonparticulate antacid (eg, sodium citrate,
ranitidine or metoclopramide)
 Preoxygenation women because of their reduced
functional residual capacity
(Grant ,UpToDate, 2016NICE Guideline 2004&2011)
ABOUBAKR ELNASHAR

23. 10. FOR PREVENTION OF REGIONAL
ANESTHESIA-INDUCED HYPOTENSION:
1. Volume expansion using (500 IV Saline or Ringer
lactate)
2. Vasopressors: ephedrine or phenylephrine
3. Uterine displacement 15 degree (left).
4. All of the above
ABOUBAKR ELNASHAR

24. Choice of Anaesthesia for CS
It is influenced by :
1. Urgency of the procedure
2. Maternal status
3. Specific contraindications
4. Physician and patient preference.
(Grant ,UpToDate, 2016)ABOUBAKR ELNASHAR

25. 11. CS TECHNIQUE: WHICH IS CORRECT?
1. The transverse incision of choice should be
Pfannenstiel Incision
2. When there is a well formed lower uterine
segment, sharp rather than blunt extension of the
uterine incision
3. Placenta should be removed using controlled cord
traction and not manual removal
ABOUBAKR ELNASHAR

26. Joel Cohen Vs Pfannenstiel
The transverse incision of choice should be Joel Cohen
incision because it is associated with:
 Less
 Fever
 Pain
 analgesic requirements
 blood loss
 Shorter
 duration of surgery
 hospital stay.
(Hofmeyr , Cochrane Database Syst Rev. 2007; NICE 2004 & 2011)
ABOUBAKR ELNASHAR

27. Joel Cohen Incision
 Skin incision:
 Straight
 3 cm below the line
that joins anterior
superior iliac spines
slightly higher than
Pfannenstiel
 Subseqent layers
opened bluntly
if necessary extended
with scissors and not a
knife. ABOUBAKR ELNASHAR

28. Pfannenstiel Incision
 Skin:
 Curved incision
 two fingers breadths
above the symphysis
pubis
 midportion of the incision
within the shaved area of
the pubic hair
 Sheath:
Transverse incision .
 Rectus M
Separated bluntly
 Parietal peritoneum
incised at the midline ABOUBAKR ELNASHAR

29. When there is a well formed lower uterine segment,
blunt rather than sharp extension of the uterine
incision should be used because it reduces;
 Blood loss
 Incidence of postpartum hemorrhage
 The need for transfusion at CS
Placenta should be removed using controlled cord
traction and not manual removal as this reduces
the risk of
 endometritis
 blood loss without increasing operating time.
(NICE Guideline 2004 &2011)
ABOUBAKR ELNASHAR

30. 12. THE FOLLOWING MANOEUVRES MAY BE USED
FOR FLOATING HEAD
1. Rotation of chin or occiput to the front and
application of forceps
2. Kielland forceps application (Warenski method)
with traction on the foetal head as occipito
transverse, then rotation to the occipito-anterior
position and delivery by extension
3. Vacuum extraction.
4. All of the above
ABOUBAKR ELNASHAR

31. Floating head:
A high floating head:
extension of the uterine wound
delay in delivering the infant.
ABOUBAKR ELNASHAR

32. 13. WHICH IS NOT RECOMMENDED IN MANAGEMENT OF
DEEPLY IMPACTED HEAD?
1. Deepen the plane of anaesthesia, achieve uterine
relaxation if the presenting part has been gripped
tightly.
2. Head high position of the patient
3. Place a hand in the lower uterine segment in the
standard fashion to cup and then disengage the foetal
head.
4. An assistant can place a sterile, gloved hand into
the vagina from the introitus and disengage the foetal
head from below
5. Lower vertical incision if a constriction ring is
suspected.
ABOUBAKR ELNASHAR

33. Head low position to disimpact the foetal head, along
with upward pressure on the foetal shoulder by the
operator.
ABOUBAKR ELNASHAR

34. 14. WHICH OF THE FOLLOWING IS WRONG
1. Extraperitoneal repair of the uterus is recommended
2. Two-layer uterine closure rather than a one-layer
3. Neither the visceral nor the parietal peritoneum
should be sutured
4. Routine closure of the subcutaneous tissue space
5. Mass closure with slowly absorbable continuous
sutures for midlune abdominal incision
ABOUBAKR ELNASHAR

35.  Extraperitoneal repair of the uterus is not
recommended because
 more pain
 It does not improve operative outcomes such as
haemorrhage and infection
(Int J Gynaecol Obstet. 2011. NICE Guideline 2004 & 2011)
 7 additional RCTs 3183 women,
febrile complications and surgical time were similar
between uterine exteriorization and intraabdominal
repair
decision to exteriorize the uterus should be guided by
surgen preference
(ASRM, 2014)
ABOUBAKR ELNASHAR

36. 2 layer not one layer:
The effectiveness and safety of single layer
closure of the uterine incision is uncertain.
Single-layer closures were associated with a higher
uterine rupture risk than double-layer closure in
women attempting VBAC
(Berghella UpToDate, 2016; Int J Gynaecol Obstet. 2011)
ABOUBAKR ELNASHAR

37. Neither the visceral nor the parietal peritoneum should
be sutured
 Reduces:
 operating time
 postoperative analgesia
 improves maternal satisfaction
(Wilkinson& Enkin (Cochrane Review) 1997. 2004.NICE Guideline 2004 &
2011 Layell et al, 2006)
ABOUBAKR ELNASHAR

38. Routine closure of the subcutaneous tissue space
should not be used, unless the woman has more than
2 cm SC fat
{does not reduce the incidence of wound infection}
(NICE Guideline 2004 & 2011)ABOUBAKR ELNASHAR

39. In the rare circumstances that a midline abdominal
incision is used at CS:
 mass closure with slowly absorbable continuous
sutures should be used
{ fewer incisional hernias and
less dehiscence than layered closure}
(NICE Guideline 2004 & 2011)ABOUBAKR ELNASHAR

40. 15. WHAT ARE INDICATIONS FOR VERTICAL
UTERINE INCISION?
1. Poorly developed Lower uterine segment in extreme
preterm
2. Fetal abnormality as conjoined twins.
3. Cancer Cervix
4. Postmortem delivery
5. All the above
ABOUBAKR ELNASHAR

41. INDICATIONS FOR VERTICAL UTERINE
INCISION?
1. Poorly developed L US + Extr. preterm
2. Fetal abnormality as conjoined twins.
3. Cancer Cervix
4. Postmortem delivery
5. Back down transverse lie
6. Lower U segment leiomyoma
7. Densely adherent bladder
8. Anterior placenta previa or accreta
ABOUBAKR ELNASHAR

42. 16. OPERATIONS NOT RECOMMENDED AT THE
TIME OF CS
1. Abdominoplasty
2. Minilap- cholecystectomy or laparoscopic
cholecystectomy
3. Appendectomy
4. Hernia repair
5. Myomectomy
ABOUBAKR ELNASHAR

43. Abdominoplasty at the time of CS
not recommended to perform
It is recommended to wait for several months or
a year
Minilap cholecystectomy or laparoscopic
cholecystectomy
in selected patients is safe
Appendectomy or hernia repair
can be combined with CS when indicated
ABOUBAKR ELNASHAR

44. Myomectomy during CS with
does not appear as hazardous as was thought
before.
1. Careful patient selection
2. Adequate experience
3. Efficient haemostatic measures
4. Bilateral uterine a ligation may be used to
minimize blood loss
ABOUBAKR ELNASHAR

45. Myomectomy may be considered for:
1. Accessible subserous accessible myoma less
than 6 cm
2. Myoma in lower segment to avoid upper segment
incision
3. Pedunculated myoma
4. Intrmaural myoma may be removed with caution
Myomectomy should be avoided:
1. Inaccessible myoma
2. Large fundal, intramural fibroids
3. Fibroid greater than 6 cm in diameter
ABOUBAKR ELNASHAR

46. 17. CS IN MORBIDLY OBESE PREGNANT WOMEN.
ALL IS CORRECT EXCEPT
1. Preanesthetic evaluation
2. Low transverse skin incisions are feasible and
preferred to vertical skin incisions in these women.
3. Closure of the subcutaneous layer is generally
recommended.
4. Vertical uterine incision is superior
ABOUBAKR ELNASHAR

47. CS in Morbidly obese pregnant women (BMI>40 kg/
m2)
Increased risk of pregnancy complications
increased rate of CS
Preanesthetic evaluation
Scheduled cesarean.
 Low transverse skin incisions are feasible and
preferred to vertical skin incisions in these women.
 Closure of the subcutaneous layer is generally
recommended.
 Transverse uterine incisions are definitely superior,
impact future pregnancy outcomes, and must be
the first choice.
 The role of subcutaneous drains still remains
controversial
ABOUBAKR ELNASHAR

48. 18. CS IN MORBIDLY OBESE PREGNANT WOMEN.
ALL IS CORRECT EXCEPT
1. The dose of thromboprophylaxis needs to be higher
2. Prophylactic antibiotics reduce postoperative
infections
3. Weight reduction postpartum
4. Breast feeding is not recommended
ABOUBAKR ELNASHAR

49.  The dose of thromboprophylaxis needs to be higher
and adjusted according to body weight.
 Prophylactic antibiotics reduce postoperative
infections in obese women and are highly
recommended
 Weight reduction postpartum, with a permanent
change in diet and lifestyle.
 Breast feeding, which may promote further weight
reduction, must be encouraged.
ABOUBAKR ELNASHAR

50. 19. TO PREVENT SURGICAL SITE INFECTION
AFTER CS. All is correct except
1. Maintain strict glycemic control in DM
2. Higher dose of preoperative antibiotics in obese
3. IV antibiotic prophylaxis
4. Shaving for preoperative hair removal. If hair removal
is necessary to perform the skin incision
ABOUBAKR ELNASHAR

51.  TO PREVENT SURGICAL SITE INFECTION AFTER
CS
1. Maintain strict glycemic control in DM
2. Higher dose of preoperative antibiotics in obese
3. IV antibiotic prophylaxis
4. Clippers for preoperative hair removal. If hair removal
is necessary to perform the skin incision
ABOUBAKR ELNASHAR

52. 20. TO PREVENT SURGICAL SITE INFECTION
AFTER CS. All is correct except
1. Chlorhexidine-alcohol for skin prep immediately
before surgery
2. Alcohol based hand rub for preoperative
antisepsis
3. Close the skin with staples
4. Closure of the subcutaneous fat for women with a
tissue thickness of more than 2 cm
ABOUBAKR ELNASHAR

53.  TO PREVENT SURGICAL SITE INFECTION
AFTER CS
1. Chlorhexidine-alcohol for skin prep immediately
before surgery
2. Alcohol based hand rub for preoperative
antisepsis. {more effective than conventional
surgical scrub}
3. Close the skin with subcuticular sutures
{lower risk of wound complications compared with
staples}
4. Closure of the subcutaneous fat is associated
with a decreased risk of wound disruption for
women with a tissue thickness of more than 2 cm
ABOUBAKR ELNASHAR

54. RECOMMENDED
 Use (Joel Cohen incision)
 Use blunt extension of the uterine incision: cephalad-
caudad direction
 Use controlled cord traction for removal of the
placenta
 Close the uterine incision with two suture layers
 Prophylactic antibiotics: Single dose, ampicillin or
first-generation cephalosporin 15-60 min prior to
incision
 Prevention of PPH
 Oxytocin 5 IU by slow IV injection at CS
 Oxytocin infusion10-40IU in 1 L crystalloid over 4-8 h
ABOUBAKR ELNASHAR

55. NOT RECOMMENDED
 Close subcutaneous space (unless > 2 cm fat).
 Use superficial wound drains.
 Suture either the visceral or the parietal peritoneum
 Manually remove the placenta.
 Supplemental oxygen Does not reduce morbidity
from infection
 Cervical dilation Does not reduce morbidity from
infection
 Subcutaneous drain Does not reduce wound
morbidity
ABOUBAKR ELNASHAR